Healthcare Access Copy

HEALTHCARE ACCESS COPY

Patient Name:    Date of Birth:

Patient Contact Information

Requestor / Representative (if not patient)

Requestor Name:    Relationship:

If acting as representative, verification provided: Government ID    Power of Attorney / Legal Documentation

Records Requested

I request access to or copies of the following records. Select all that apply and describe with specificity when necessary.

Entire Medical Record    Laboratory / Pathology Reports    Imaging / Radiology Reports

Clinic / Progress Notes    Billing / Financial Records    Other:

From:    To:

Format and Delivery

I request records be provided in the following format(s):   Paper    Electronic PDF    Encrypted Email

Upload to Patient Portal    Fax to:

Fees and Acknowledgement

I understand that the provider may impose reasonable, cost-based fees for copying, mailing, labor and supplies, and that I will be informed of the estimated fee prior to release when required. I authorize the provider to charge applicable fees as allowed by law.

I acknowledge and accept potential fees for copies and delivery.

Purpose of Disclosure

Purpose: Personal Use    Continuing Care    Insurance    Legal    Other:

Medical History Summary (for provider assistance)

Authorization and Legal Terms

I hereby authorize the release of the records specified above, including any protected health information contained therein. This authorization specifically includes mental health records, communicable disease information (including HIV/AIDS-related information) and substance abuse treatment records, unless I have expressly excluded such categories below.

Exclude the following category(ies):

I understand that I may revoke this authorization at any time by submitting a signed, written notice to the health information management department, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on: . If no date is provided, the authorization will expire one year from the date of signature.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I release the provider, its employees and agents from any legal responsibility or liability for the release of the above information to the extent described and authorized herein.

I understand that refusal to sign this authorization will not affect my ability to obtain treatment, enrollment in a health plan, or eligibility for benefits unless the information is necessary for determination of such benefits. I certify that this authorization is given voluntarily and that the information provided in this form is true and accurate to the best of my knowledge.

By signing below I authorize release of my medical records as specified above and acknowledge receipt of a copy of this authorization upon request.

I acknowledge that I have been provided with the privacy practices and understand my rights regarding protected health information.

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